Provider Demographics
NPI:1407907348
Name:BRADLEY, MICHAEL JACK
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JACK
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6551 HARRIS PKWY
Mailing Address - Street 2:STE 205
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-6103
Mailing Address - Country:US
Mailing Address - Phone:817-370-6118
Mailing Address - Fax:817-370-7118
Practice Address - Street 1:6551 HARRIS PKWY
Practice Address - Street 2:STE 205
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6103
Practice Address - Country:US
Practice Address - Phone:817-370-6118
Practice Address - Fax:817-370-7118
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR0166156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1249980001Medicare NSC